Ask Dr. Keith Roach M.D
Bariatric patients must caution with meds
DEAR DR. ROACH: In February, I experienced a massive gastrointestinal bleed, resulting in a seven-pint transfusion. Luckily for me, I was in my bariatric doctor's office for a well checkup when I used the toilet, and I had the presence of mind, or overcame modesty, to ask a nurse to verify if that was indeed blood in the toilet.
When the doctor was told what was happening, his first assumption was hemorrhoids, until he heard that I was taking meloxicam. At that point, his entire demeanor changed. To make a long story short, he says he sees two patients a week in the emergency room due to meloxicam-caused ulcers in bariatric patients. He used the term 'epidemic.'
I was prescribed meloxicam specifically because I was a bariatric patient and knew I could not take NSAIDS. -M.W.
ANSWER: All types of bariatric surgery increase the risk for ulcers in whatever of the stomach is left after the procedure. Most people with bariatric surgery are told to avoid nonsteroidal anti-inflammatory drugs, and meloxicam sometimes is recommended specifically because of its lower risk of bleeding, as it has minimal effect on platelets.
However, the key word is 'lower' risk, which means that it still increases risk of bleeding. This probably is through its effect on prostaglandins, which protect the lining of the stomach. So, if many people with bariatric surgery are recommended meloxicam, it certainly will cause a disproportionate amount of ulcers and bleeding. It's much safer to avoid any kind of anti-inflammatory medicine, including celecoxib (also called Celebrex, the other medication most commonly recommended in people after bariatric surgery).
Acetaminophen (Tylenol) is the safest over-the-counter pain medication. Unfortunately, acetaminophen doesn't work for everybody. The use of misoprostol (Cytotec) or an H2 blocker such as famotidine (Pepcid) in combination with an NSAID reduces bleeding risk.
However, since bleeding risk can never be completely eliminated, there are some important things to know: NSAIDs increase bleeding risk in everyone — this risk is especially large in those with a history of bariatric surgery; and any sign of bleeding, especially dark stools, should be taken very seriously and should be immediately brought to the attention of your bariatric surgeon, regular doctor or other provider.
DEAR DR. ROACH: What is the difference between the innate immune system and the adaptive immune system? -L.P.B.
ANSWER: The innate immune is the part of the immune system that can respond to pathogens it hasn't previously seen. NK cells -so-called natural killer cells, the best name ever for an immune cell — are part of the innate immune system, as are the macrophage/monocyte cells and neutrophils.
This is opposed to the adaptive immune system, which requires exposure to the germ. The major cells of the adaptive immune system are the B-cell and T-cell systems. The adaptive system can be primed by vaccines, which is critically important for conditions in which the innate immune system fails or fails to respond quickly enough. It responds in situations in which bacterial toxins can build up (e.g., tetanus), bacteria overwhelm us (e.g., bacterial meningitis) or the virus damages critical structures (e.g., poliomyelitis). In many cases, the memory cells of the adaptive immune system allow for lifelong immunity, whether from natural infection or vaccination. Unfortunately, some bacteria and viruses have figured out ways around it, and other times they change their structure sufficiently to be able to reinfect us (e.g., influenza), which is why annual vaccination is required.